Provider Demographics
NPI:1912958539
Name:DEMOSS, MARY LUCINDA (OD)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:LUCINDA
Last Name:DEMOSS
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:23002 LAKE CENTER DR
Mailing Address - Street 2:
Mailing Address - City:LAKE FOREST
Mailing Address - State:CA
Mailing Address - Zip Code:92630-6801
Mailing Address - Country:US
Mailing Address - Phone:949-454-1064
Mailing Address - Fax:949-454-4111
Practice Address - Street 1:31722 RAILROAD CANYON RD
Practice Address - Street 2:
Practice Address - City:CANYON LAKE
Practice Address - State:CA
Practice Address - Zip Code:92587-9486
Practice Address - Country:US
Practice Address - Phone:951-244-4444
Practice Address - Fax:951-244-1414
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2016-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA8955152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0089550Medicaid
CASD0089550Medicare ID - Type Unspecified
79754Medicare UPIN